Slide 1 Best Practices Work Group Chapter 244 Acts of 2012 Joint Policy Working Group Bureau of Health Care Safety and Quality Cheryl Campbell, M.S.,J.D. Adele Audet, R.Ph. Len Young, M.S., M.A. September 9, 2013

Slide 2 Chapter 244 Acts of 2012 Section 21 “The commissioner of public health shall convene a joint policy working group to investigate and study best practices, including those in education, prevention, screening, tracking, monitoring and treatment, to promote safe and responsible opioid prescribing and dispensing practices for acute and chronic pain with the goal of reducing diversion, abuse and addiction and protecting access for patients suffering from acute and chronic pain.”

Slide 3 Overview Agenda I. Review meeting minutes from July 26, 2013 II. Prescription Drug Abuse Epidemic – Data Review National trends in Prescription Drug Abuse Prescription Drug Abuse in Massachusetts III. Purpose of the Best Practices Workgroup IV. Example: Treatment Guideline (Number 27) – Chronic Pain the Department of Industrial Accidents. Diane Neelon, B.S., R.N., J.D. Director of the Office of Health Policy (OHP) - Executive Director of the Health Care Services Board (HCSB) V. Discussion, Feedback and Next Steps

Slide 4 Meeting Minutes

Meeting of July 26, 2013 Agenda Agenda 1. Review Minutes from April 25, 2013 Meeting 2. Discuss the Amendment to Chapter 244 of the Actsof Discuss Best Practices for Promoting Safe and Responsible Opioid Prescribing 4. Regulations Development Timeline 5. Discuss Next Steps

Slide 6 Prescription Drug Abuse Epidemic: Brief Review of National Data

Deaths are the tip of the iceberg National Center for Injury Prevention and Control, Centers for Disease Control and Prevention

National Data: ED Visits Related to Nonmedical Use of Narcotic Pain Relievers (2004 and 2011) Data Source: Drug Abuse Warning Network (DAWN) Report 2013 (Only includes data up to 2011)

Slide 9 Massachusetts Data

MA Death Data Coded according to WHO International Classification of Diseases, Tenth Revision –Based on text that is written on death certificates –Data shown here is not directly based on toxicology reports Nearly all overdose deaths in MA are reviewed and certified by MA Office of the Chief Medical Examiner –Standardized policies and protocols (quality data) –Determine the manner and cause of death – written on death cert. –2005 policy change regarding assignment of manner of death in overdose deaths where no evidence of suicide from “undetermined intent” to “unintentional.”

Leading Mechanisms of Injury Deaths, MA Residents, 2010 (Total N= 3,066) *Includes occupants, motorcyclists, and unspecified persons Sources: Registry of Vital Records and Statistics, MA Department of Public Health; CDC, WISQARS Age Adjusted Rate: 43.3 per 100,00 (vs per 100,00 in U.S.)

Massachusetts - Drug-related deaths by drug category, NOTES: Alcohol row includes alcohol in combination with other drugs (all ages) and alcohol alone in decedents under age 21. ALL DRUGS822 Alcohol216 Antidepressants90 Antipsychotics25 Benzodiazepines86 Misc. anxiolytics, sedatives, and hypnotics30 Opiates/opioids592 **(72% of all drugs) – Heroin (specified)90 – Methadone94 – All other opiates/opioids432 Misc. analgesics/combinations24 Anticonvulsants11 Muscle relaxants14 Source: Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2010: Area Profiles of Drug-Related Mortality. HHS Publication No. (SMA) , DAWN Series D-36. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Co-Occurrences of Select Agents among Poisoning/Overdose Deaths, MA Residents Source: Registry of Vital Records and Statistics, MDPH

Opioid-related Poisoning Deaths by Selected Age Subgroups, MA Residents Source: Registry of Vital Records and Statistics, MA Department of Public Health Rates among individuals 65+ for all years and among individuals for years are based on counts <20 and considered unstable. 2010: Highest rates among individuals years of age.

US and MA Age-Adjusted All Poisoning and MA Opioid-related Death Rates, Sources: All- poisoning rates from CDC, WISQARS web-based query (Accessed 2/19/2013) Opioid-related poisoning from Registry of Vital Records, MDPH. 99% increase in all poisoning death rate in MA from ; 18% decrease in rate from 2006 to % increase in opioid-related poison death rate in MA from ; 13% decrease in rate from 2006 to 2010.

Key Data Points National: –Opioid deaths are just the tip of the iceberg. –There is a need for different strategies for early intervention. Statewide: –The leading mechanism of injury deaths in MA is associated with poisoning/drug overdose. –Opiates and opioids accounted for 72% of all drug-related deaths in –Overdose deaths related to co-occurrences of opioid among benzodiazepines is on the rise. –2010: Highest rates among individuals years of age. –99% increase in all poisoning death rate in MA from ; 18% decrease in rate from 2006 to –73% increase in opioid-related poison death rate in MA from ; 13% decrease in rate from 2006 to 2010.

Slide 17 Purpose of the Best Practices Work Group Statutory Approach to Address the Prescription Drug Abuse Epidemic in Massachusetts Adele Audet, R.Ph. Assistant Director of the Drug Control Program

Slide 18 Best Practices Workgroup Goals: Develop recommendations for: reducing diversion, abuse of opioid prescription medications, and addiction to opioid prescription medications while protecting access for patients with acute and chronic pain. Study findings and workgroup recommendations will be submitted in a report to the legislature.

Slide 19 Task Investigate and study best practices for promoting safe and responsible opioid prescribing and dispensing practices for acute and chronic pain. What are the best practices in: EducationMonitoring Tracking Screening PreventionTreatment

Question 1 Educate whom? Health Care Providers Patients/Care Givers Insurance Companies Drug Companies Professional Schools Regulators Law Enforcement

Question 2 Treatment of Acute/Chronic Pain in the Setting of Reducing Diversion, Abuse and Addiction Treatment Specialists Emergency Services Patients/Care Givers Professional Schools

Morphine Equivalent Dose

Slide 23 Treatment of Chronic Pain : Guideline Number 27 Workers’ Compensation Claims Department of Industrial Accidents Diane Neelon; BS, RN, JD Director of the Office of Health Policy (OHP) - Executive Director of the Health Care Services Board (HCSB)

Slide 24 Discussion and Feedback

Side by Side Comparison of Guidelines and Federation of State Medical Boards Model Policy Guidelines from the MA Department of Industrial Accidents Federation of State Medical Boards Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain Topics "It is recommended that use of opioid analgesic and sedative hypnotic medications in chronic pain patients be used in a very limited manner, with total elimination desirable whenever clinically feasible." "Physicians must understand the relevant pharmacologic and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient." Initial workup should include Physical exam and baseline initial drug screen. Systems review, physical exam, laboratory investigations as indicated. Additional factors to consider Psychosocial history, mechanism of injury, pain history, medical management history, substance use/abuse, and other factors that may affect treatment outcome. Social and vocational assessment, personal and family history of alcohol or drug abuse Psychological risk factors screening Psychosocial evaluation, as well as, concomitant interdisciplinary rehabilitation treatment whenever appropriate. Initial exam to be performed by a psychologist with a PhD, PsyD, EdD credential, or Psychiatric MD/DO may perform the initial comprehensive evaluations. Screen for depression, history of substance use disorder and other mental health disorders.

Side by Side Comparison of Guidelines and Federation of State Medical Boards Model Policy (cont’d.) Guidelines from the MA Division of Industrial Accidents Federation of State Medical Boards Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain Goal of pain treatment Ongoing effort to gain improvement in activities of daily living, and social and physical function as a result of pain relief should be a primary goal with the use of any medication. Reasonably attainable improvement in pain and function; improvement in pain-associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications. Treatment Agreement Patient Physician Agreement – All patients on long term opioids must have a written, informed agreement. The agreement should discuss side effects of opioids, results of use in pregnancy, inability to refill lost or missing medication/prescription, withdrawal symptoms, requirement for drug testing, necessity of tapering, and reasons for termination of prescription. Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is recommended. Initiating Opioid Treatment Consultation or referral to a pain specialist should be considered when the pain persists beyond the expected time for tissue healing of the injury. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 days) and with specified evaluation points.

Side by Side Comparison of Guidelines and Federation of State Medical Boards Model Policy (cont’d.) Guidelines from the MA Division of Industrial Accidents Federation of State Medical Boards Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain Ongoing Monitoring and Adapting the Treatment Plan Ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Visits initially at least every 2-4 weeks for the first 2-4 months of the trial, then At least once every 6-8 weeks while receiving opioids. If there has not been an overall improvement in function, opioids should be tapered and discontinued. Apply the “5As” of chronic pain management when monitoring patient on chronic opioid therapy; these involve a determination of whether the patient is experiencing a reduction in pain (Analgesia), has demonstrated an improvement in level of function (Activity), whether there are significant Adverse effects, whether there is evidence of Aberrant substance-related behaviors, and mood of the individual (Affect). Testing for Adherence to Treatment Plan Use of random drug screening at least twice and up to 4 times per year for the purpose of improving patient care.Periodic drug testing and pill counting. Addiction and diversion prevention measures The total daily dose of opioids should not be increased above 120 mg of oral morphine or its equivalent. If more than two opioids are prescribed for long-term use; and/or the total daily dose of opioids is above 120 mg of oral morphine or its equivalent; and/or opioids with central nervous system depressants are prescribed, then a second opinion from a Pain Medicine Specialist (i.e. Board Certified) is strongly recommended. Evidence of misuse of prescribed opioids demands prompt intervention by the physician. If opioid therapy is discontinued, the patient who has become physically dependent should be provided with a safely structured tapering regimen.

Slide 28 Prescription Monitoring Program (PMP) and patient prescription histories: use in promoting safe and responsible opioid prescribing Len Young, M.S., M.A. Epidemiologist for the Prescription Monitoring Program

29 Prescription Monitoring Program Prescriber Survey: Preliminary Findings 336 baseline surveys received as of 1/23/ % of respondents said Unsolicited Reports (both electronic and hard copy) “very” or “somewhat helpful” Only 8% said they were “aware of all or most of other prescribers” in report Only 9% said “based on current knowledge, including report, patient appears to have legitimate medical reason for rxs from multiple prescribers” Source: MDPH and P. Kreiner et al., Brandeis University

PMP System Overview State PMP DispensersPrescribers Law Enforcement & Professional Licensing Agencies Pharmacists Data Submitted Reports Sent Reports Sent Reports Sent *Other groups may also receive reports other than those listed PMP System Overview

What is doctor shopping? Patient seeks prescription without informing a prescriber that he/she has obtained prescriptions from other prescribers How can PMP data be used to measure it? Patients with prescriptions from multiple prescribers, filled at multiple pharmacies, can be identified in PMP data States use different thresholds PMP and Doctor Shopping

Prescription Information Collected Patient identification: –Name & Address –DOB & Gender Prescriber Information Dispensing Pharmacy Information Drug Information, e.g. –NDC # = name, type, strength, manufacturer –Quantity & date dispensed

Comparison of Doctor Shopping Thresholds

Percent Difference from Declining Rates of Doctor/Pharmacy Shopping in MA

Comparison of PMP Requirements

Slide 37 Next Steps

Slide 38 Best Practices Work Group Report: Recommendations for MA Department of Public Health Epidemiology to Policy Group

Background From Epidemiology to Policy: Prescription Drug Overdose Meeting, Centers for Disease Control and Prevention, April 22-23, 2013 –Using epidemiology data to develop educational programs –MA Department of Public Health Representatives and Collaborators in this Initiative: Madeleine Biondolillo, M.D., Director of the Bureau of Health Care Safety and Quality Holly Hackman, M.D., M.P.H., Epidemiologist, Injury Prevention and Control Program Hilary Jacobs, LICSW, LADC I, Director of the Bureau of Substance Abuse Services

Slide 40 Epi to Policy Group: Current/Future Initiatives Identify a best practice training program for opioid prescribing for prescribers and pharmacists. Provide a catalogue of educational opportunities for Prescription Monitoring Program use and best practices. Develop principles of care guidelines published by describing best practices and how practice in specific areas can be improved. Provide guidance on how to talk to patients suspected of abuse and how to say no to prescribing opioids.

Slide 41 Next Meeting Topics Investigate and study best practices for promoting safe and responsible opioid prescribing and dispensing practices for acute and chronic pain. What are the best practices in: EducationMonitoring Tracking Screening PreventionTreatment

Slide 42 Thank you Next meeting: Wednesday October 9, :30 AM – 11 AM 99 Chauncy St., 11 th Floor Boston, MA